The Community Clinic is a primary healthcare network unique to Bangladesh. This is a public health brand often associated with Bangladesh’s premier, Sheikh Hasina. The idea was conceptualised in 1996 with a target of resolving the problem of last-mile healthcare delivery.
At the time, there was global policy agreement that in developing nations only preventative healthcare could best keep health-related expenses in check. Bangladesh had applied this principle in the war-trodden post-independence period after 1972. During the initial years of the country’s existence, a local-level health network, the Thana Health Complex network, was established to deliver primary healthcare for the grassroots population. In 1978, even though it was newly resource-poor, Bangladesh signed the Alma Ata Declaration pledging ‘health for all’ by the year 2000.
A tiered health system was developed in subsequent years that encompassed different local government levels. However, poor health indicators meant that the policy needed reform. Basic healthcare among rural and low-income people required more attention. The idea of the community clinic was born in this context. Community clinics would transcend the local government-tied tiered system and take healthcare deeper into rural areas.
In developed nations, healthcare is strictly contingent on health insurance. Despite having the best drugs and the best medical protocols, and spending 9–10% of gross domestic product on healthcare, many governments in these nations cannot deliver healthcare to all, given this dependency on payment through insurance. Ironically, Bangladesh, a developing country, decided to take healthcare to the villages through its community clinics without any conditional payment format.
At community clinics, patients receive treatment, drugs, needs-based healthcare and immunisation services for free. These clinics represented the bottommost tier, an added line of defence, aligned with the local subdistrict healthcare system, the upazila tier. In the future, community clinics can become a steppingstone towards a decentralised health delivery system.
Community governance system
In Bangladesh, the Community Clinic is a fast-tracked policy implemented through a community-based healthcare operational plan. The strategy inculcates health services, family planning and nutrition for the grassroots populace. The background work on the concept took two years. Then, between 1998 and 2001, almost 10,000 community clinics sprouted up across the country. Bangladesh’s new government in 2001 then disincentivised the community clinic policy, and many clinics were shut down. They were reanimated in 2009 through another policy initiative called the Revitalisation of Community Health Care Initiatives.
In Bangladesh, the Community Clinic is a fast-tracked policy implemented through a community-based healthcare operational plan.
A Bangladeshi community clinic is a public–private partnership venture. The locals donate the land and the government builds the structure and provides the service and essential medicines. The executive structure, also called the community group, comprises around 15 people depending on the catchment area. The governing team should consist of one-third women. The community group is chaired by the area’s elected local government representative. The land donor (or a representative) is a permanent member of the community group.
The services at the community clinics are provided by a service team consisting of a Community Health Care Provider along with two assistants dedicated to healthcare and family welfare. The team manages services like patient visits and vaccination schedules. Each clinic serves between 6,000 and 10,000 people within its catchment area. This service team, with inputs from local health-related government officials, develops one-year strategic plans. The team and the community group meet every quarter.
Some services worthy of mention provided through the community clinics are as follows:
- Health services like managing common ailments (such as tuberculosis and diabetes), screening for hypertension and referral for non-communicable diseases to the upper tier;
- Nutritional education, counselling and dispensing supplements through community volunteers;
- Reproductive health, family planning and newly married couple counselling;
- Monitoring expectant and new mothers to receive designated home visits;
- Vaccination support;
- Health services for elderly patients;
- Normal delivery provision;
- Issuance of birth and death certificates;
- Contraceptive dosage support and mobilisation of volunteer (midwives, local civil society and traditional medical practitioners) networks;
- Information dissemination through local media.
At national level, Bangladesh’s community clinics are governed under continuous multiyear operational plans. An independent agency, the Community Clinic Health Assistance Trust, oversees the expansion and fundraising strategy of the community clinic network.
The broad aspirations
The Community Clinic initiative has clear visions:
- Make preventative and primary healthcare accessible to underserved people;
- Be the one-stop-shop for the catchment area;
- Reduce the patient burden in upper-tier hospitals;
- Support the digitalisation of the referral system; and
- Lay the foundations for universal health coverage.
Bangladesh’s community clinic executive structure is designed for gender parity, meaning 54% of all healthcare providers are women. By targeting marginalised remote populations, the initiative acts as an inequality-reducer. A total of 96% of community clinics update their activities online, so they can be easily regulated. The community clinic network gives professional opportunities to a million people, which includes medical professionals, operations officers, community volunteers and local administrative officials.
Community Clinic is a public health initiative that has had long growth momentum in Bangladesh. In 2023, the United Nations recognised it as an exemplary public health model.
Challenges and solutions
Primary healthcare is the backbone of human development. Countries like Singapore, South Korea and Malaysia founded their sophisticated health systems on a strong preventative primary care base. Bangladesh’s Community Clinic initiative is based on the same structure. However, the infrastructure and service quality are very basic considering the country’s economic performance. Collaboration among strategic stakeholders for affordable quality services could significantly improve the community clinic network.
Countries like Singapore, South Korea and Malaysia founded their sophisticated health systems on a strong preventative primary care base. Bangladesh’s Community Clinic initiative is based on the same structure.
Health information system: The District Health Information System 2 (DHIS2) is a prominent health information system for lower-middle income countries. It is used in over 70 countries, including in Bangladesh, where it integrates all domains related to health service delivery. There are two sides of data management – one related to data generation and the other to analysing data for policy-making.
In Bangladeshi community clinics, DHIS2 is used in reporting certain types of cases. However, most of the data are not disaggregated into individuals. This means 1,000 services may show the same people getting multiple services and not necessarily 1,000 separate cases. Securing vast amounts of patient data is a futile expense if data are not analysed. For example, if community clinics in a specific region are reporting excessive numbers of diabetic patients, then channelling more diabetic-combatting drugs and diabetic awareness programmes can better tackled the disease.
Governance and human resource policies: Bangladesh’s independently established Community Clinic Health Assistance Trust monitors all recruitment. However, heavy bureaucracy means a clear human resource policy has not yet been stipulated, leaving community clinic employees in limbo. Bangladeshi policy-makers have to decide whether its Directorate General of Health Services or the Community Clinic Health Assistance Trust will be the main regulatory agency for community clinics.
The community clinic in-charge, the Community Health Care Provider, does not have job security. Most community clinic-related jobs are project-based temporary jobs. Furthermore, the person in-charge needs to be closely monitored and retrained to improve their performance.
Service rejuvenation: Many community clinics that shut down under the deprioritising policy in the 2000s have become dilapidated. Renovation is required to revive them. Meanwhile, community clinics can also be hubs for family planning-related ground awareness. It will directly reduce the maternal mortality and neonatal mortality rate.
Community clinics do not have in-house doctors. Research shows that community clinic goers demand having doctors at the clinics. Since there are inadequate numbers of doctors in Bangladesh, any increase will rise the cost of services for the government. Utilising telemedicine tech for doctor support could enhance service quality. Exploring collaborations between community clinics and medical mobile apps by startups can help in screening for non-communicable diseases and back referrals.
A robust information and referral system: Community clinics are the first stop, and referrals are usually made to the immediate upper tier, the upazila (subdistrict) health complexes. It is important to have back referrals to community clinics since the patient will ultimately return home to be managed there.
In Bangladesh, a fully integrated health information system will be established only when all citizens receive their unique ID. In such a system, the patients or the healthcare provider can universally access the patient data to ensure a continuum across the different levels of health service delivery. The system will also track service providers and pharmacists. A referral, back referral and one-page screening system will also avoid unnecessary burnout of doctors and accidental mishaps.
Stakeholder engagement: As a public–private initiative, community clinics are designed to enable people to take ownership of their community’s health. In Bangladesh, there is a normative practice of senior doctors providing weekend services to people in their village or hometown. These doctors can be incentivised to provide the same service with the community clinic in their village or hometown. Bangladesh can also introduce an incentive for affluent citizens to adopt community clinics. Involving high-income groups in helping low-income groups can level up the quality of the care.
Universal health agenda
Bangladesh’s community clinic policy’s grand agenda is to help build universal health coverage by 2032. Globally, universal health coverage is tagged with health insurance to reduce out-of-pocket expenses. Bangladeshi community clinics are free of cost for all. But can this cost-bearing be applied to rest of the health sector? Fixing the data trends from the health information system can help health economists calculate the real financial risks.
Fixing the data trends from the community clinics’ health information system can help health economists calculate the real financial risks.
This information might help in designing risk-pooling instruments whereby patients and government share the cost of health service. Advanced economies reduce citizens’ health expenditure using multiple instruments covering extensive services. For example, in Singapore, the three basic schemes supporting citizens are MediShield, MediSave and MediFund.
MediShield is the basic health insurance funded from a centralised provident fund. It covers hospital stays, dialysis and chemotherapy. MediSave is a medical savings scheme where individuals set aside a part of their income, to be used when MediShield falls short. All savings in MediSave grow as fixed deposits and are given back to the patient at the end of life. MediFund is an endowment fund of the government that safeguards individuals when MediShield and MediSave are both exhausted.
Vietnam’s Social Health Insurance is publicly funded and its services are similar to Bangladesh’s Community Clinic. Brazil’s health system, known as SUS (Sistema Único de Saúde), also has similarities with Bangladesh’s health system. Its Family Health Strategy, designed to expand primary care, is structured like Community Clinic. However, its strategy includes a doctor, a nurse, a nurse assistant and more community health workers covering 2,000-4,000 individuals in a catchment area.
Bangladesh’s population size and growing economy demand instruments for financial protection from health expenses. Incremental expansion is possible in due course of time either through public funds or through private co-payments but a framework needs to be established.
End comments
Diseases are not class-sensitive; anybody can be affected by any disease at any time. However, preventative measures, health education and basic primary care can nurture a healthy demography that will lower the cost of the disease burden and deliver a demographic dividend.
Healthcare is a sensitive topic in both the wealthiest and the poorest nations. The perfect society where all citizens are fully covered to receive cutting-edge healthcare is very much an illusion. Bangladesh being a developing nation is striving to achieve as much as it can.
Community clinics were born out of commitment towards those left behind in rural Bangladesh. It has become an integral part of the entire infrastructure of Bangladesh’s healthcare ecosystem. The onus is now on the people, policy-makers and health service providers to strengthen the clinics towards achievement of the universal health agenda.
Photo ©️ Mahmud Hossain Opu